Completing Yo r Q alit Completing Your Quality Improvement Plan
Completing Yo r Q alit Completing Your Quality Improvement Plan Completing Yo r Q alit Completing Your Quality Improvement Plan
VAP, CLI– Follow BundlesVAP:• Head of bed up (30 ⁰, ideal 45⁰)• Daily spont. breathing trial (see ifcan extubate)• Appropriate level lof sedation &daily “sedation vacation”• Oral instead of nasal gastricdrainage tube• Oral ETT with port for continuousaspiration of subglotticsecretions (CASS)• Oral care protocol withchlorhexidine• General: PUD&DVT prophylaxis,nutrition, hand hygieneCLI:• Hand hygiene• Full barrier precautions• Chlorhexidine skin antisepsis• “Scrub the hub”• Daily review of need for line• Dedicated lumen for TPN• Check inflammation at each dressingchange26
VAP, CLI• If VAP, CLI persist in your hospital, why?– Regular tracking of process measures?• Which part of bundle not being executed flawlessly?Why?– Protocols, standard orders in place?– Skills of all staff verified?• Agency staff? New hires? Trainees/residents?27
- Page 1: Completing Your QualityImprovement
- Page 4 and 5: What are Required Indicators?• Fo
- Page 6 and 7: Statistical Variation in Measures
- Page 8 and 9: Rare EventsIf you had a bad eventTh
- Page 10 and 11: Patient Experience SurveyThis comin
- Page 12 and 13: Seasonal Variation• Some indicato
- Page 14 and 15: Rare EventsIf you had a bad eventTh
- Page 16 and 17: Ideas for Improvement:Change Sectio
- Page 18 and 19: Example• Our plan: improving the
- Page 20 and 21: Template: Line‐by‐Line StyleImp
- Page 22 and 23: “Improvement Initiative”• Opt
- Page 24 and 25: Falls• Hospitals tracking falls i
- Page 28 and 29: • Special considerations:C Diffic
- Page 30 and 31: ALC, ED waits, Readmissions• Thre
- Page 32 and 33: HSMR• Possible goals: reduction 5
- Page 34 and 35: Patient Experience ‐ Data• Curr
- Page 36 and 37: Setting Performance Goals and Targe
- Page 38 and 39: Part A- Overview• Provide plain l
- Page 40 and 41: Part A ‐What the organization wil
- Page 42 and 43: Part A ‐ Ideas for ImprovementFro
- Page 44 and 45: How the plan aligns with the other
VAP, CLI– Follow BundlesVAP:• Head of bed up (30 ⁰, ideal 45⁰)• Daily spont. breathing trial (see ifcan extubate)• Appropriate level lof sedation &daily “sedation vacation”• Oral instead of nasal gastricdrainage tube• Oral ETT with port for continuousaspiration of subglotticsecretions (CASS)• Oral care protocol withchlorhexidine• General: PUD&DVT prophylaxis,nutrition, hand hygieneCLI:• Hand hygiene• Full barrier precautions• Chlorhexidine skin antisepsis• “Scrub the hub”• Daily review of need for line• Dedicated lumen for TPN• Check inflammation at each dressingchange26
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